Patients' experience and satisfaction using telemedicine for outpatient services in a Tertiary Cancer Center in Qatar during COVID‐19: A cross‐sectional study

Abstract Background and Aim The coronavirus‐19 is an ongoing global pandemic resulting in millions of deaths worldwide. For a patient population at higher risk of infection, telemedicine is a promising means of providing safe and alternative care routes while minimizing their risk of exposure. This study gives insight into patients' experiences and satisfaction with telemedicine during this pandemic. Methods We conducted a cross‐sectional study on 297 patients (RR: 85%) at the National Center for Cancer Care and Research (NCCCR), Qatar. Data was collected through electronic medical records of the eligibe patient population, and phone calls were made whereby the physician read a standard introductory script followed by a survey questionnaire. We focused on patients' experience with telemedicine services amid the pandemic. This was done using a six‐point Likert scoring system of seven questions that were scaled from 1 to 6. Results More than 80% of patients somewhat to strongly agreed that telemedicine met their healthcare needs, improved their confidence in their healthcare system, and were generally satisfied with the quality of care provided. Nearly all patients (90%) understood their physicians' recommendations over the phone. In addition, more than half of the patients (89%) felt they could freely communicate their concerns. Patients also showed an inclination towards face‐to‐face consultations at 68%; however, 90% were willing to participate in future teleconsultations. Conclusion Our study indicates an overall positive experience among patients towards the use of telemedicine. Telemedicine is a safe, futuristic approach toward patient care management and, thus, provides healthcare professionals a platform to implement further patient and physician education. Even though our data also showed that patients liked in‐person visits to some degree, this needs to be looked into more in future studies.

showed that patients liked in-person visits to some degree, this needs to be looked into more in future studies.  19) a global pandemic in March 2020. 1 As of November 2021, there has been over 240 million cases worldwide and over 5 million deaths. 2 Although it has caused a burden on hospitals worldwide, it also gave an insight to the pre-existing gaps within the structure of health care systems. 3 Due to global shortage of hospital necessities such as personal protective equipment, healthcare workers were more susceptible to contracting the virus. 4 WHO has estimated that as of May 2021, at least 80,000 to 180,000 healthcare workers worldwide died due COVID-19. 5 Controlling it's spread has proven a challenge, considering asymptomatic individuals can also transmit the virus. 6 There is also a great possibility that asymptomatic affected healthcare workers amplify the spread of the virus to nonexposed patients. 7 As a consequence, hospitals worldwide were overburdened, resulting in delaying services such as outpatient appointments and elective procedures. 8 Cancer care was not an exception, many countries postponed routine cancer screening programs, and patients with diagnosed cancers experienced interruptions in their anticancer treatments. 9,10 Telemedicine provides an alternative and safer way to receive care while minimizing the risk of exposure to the virus. 11 It is the use of an electronic communication to exchange medical information. 12 This is done through a growing variety of services, such as audio or video calls, emails, and other forms of telecommunication 13,14 proving to be convenient for both patients and physicians. As a result, there has been an increase in the use of telemedicine during this pandemic, which has been shown to decrease costs and visit timing and result in high patient satisfaction.
However, there are also many obstacles faced with implementing it, such as technological illiteracy among populations without digital access, and language barriers. 15 Previous publications have illustrated the drawbacks of telemedicine including a systematic review which found that the top barriers were related to technology specific challenges, they suggested these could be overcome by training and change in management techniques. 16 Another more recent systematic review showed that common patient barriers included low technology literacy, lack of technological resources, lack of trust in technology and perceived ethical and security concerns. It also showed that there was lack of evidence in using telemedicine in the prevention and surveillance of recurrence as well as new cancers. 17 Another important consideration is the question of feasibility of telemedicine in low-income regions and elderly population.
A Retrospective cohort study found that lower income areas as well as adults aged 85 years or older were more likely to use phone visits over video visits, however lack of digital and cellular access proved to be a common challenge. 18 Practicality in the developing world is also questionable. A recent review of telemedicine in Sub-Saharan Africa demonstrates clear barriers including insufficient technological infrastrucutre and medical equipment, digital illiteracy, inaccessibility to medical care and financial barriers with lack of adquate funding. 19 Table 1 including a summary of the list of studies exploring the role of telemedicine during COVID-19.
The National Center for Cancer Care and Research is the primary cancer hospital in Qatar. It has utilized telemedicine to continue its services to its patients amid the pandemic. The objective of this qualitative analysis was to explore the experiences and satisfaction that cancer patients had with telemedicine during the pandemic. As telemedicine is new our cancer care service, we reviewed their experience to further advanced telemedicine for both hematology and oncology patients.

| METHODS
We conducted a study in a tertiary cancer care center (NCCCR) in Qatar. We were planning to include a total of 400 participants, however, we managed to enroll 297. Our inclusion criteria included patients regularly followed by telemedicine in outpatient clinics during COVID 19, patients over 18 years of age, the ability to complete the questionnaire over the phone, and no language barriers.
In addition, we excluded patients who did not respond to the phone call after five attempts (at different times on different days), patients who were abroad, patients who did not consent to answer the questionnaire, and patients who expired. Using this well-formulated questionnaire, we analyzed the patient satisfaction scale and took further comments on telemedicine to improve the clinic's services during the COVID-19 pandemic. Data was collected using phone calls with a standard introductory script that was read out by a team of physicians to the patients in their native language. A survey questionnaire was formulated to measure patients' feedback and satisfaction scales for improving telemedicine clinic services during the COVID-19 pandemic. It was divided into two main categories; category 1 comprised patients' demographics, and category 2 comprised seven questions on their feedback and satisfaction scale.
Each of the seven questions was scaled from one through six using a six-point Likert scoring system. The phone calls last for not more than 10 min for each participant. Mixed results, the discrepancy between patient and provider concern for spread of infectious disease represents an area where patients may benefit from increased education.
Telemedicine during the COVID-19 pandemic: Impact on care for rare cancers 21 10.1200/GO. 20 We asked patients to rate their telemedicine experiences on a scale of 1 to 6, as demonstrated in Figures 1 and 2. Unsurprisingly, most of our cohort (99.3%) had never experienced a telemedicine consultation before. However, once exposed to the telemedicine method, most patients (42%) agreed that this form of consultation improved their confidence in their cancer care center. This was also reflected as, collectively, more than 80% somewhat to strongly agreed they were satisfied with the quality-of-care teleconsultations provided. In addition, when asked if telemedicine met their care needs, 87% of patients collectively somewhat strongly agreed that it did. It seems evident that the level of communication through telemedicine was not compromised as most patients' felt that they could freely talk over the phone, with 89% somewhat to strongly agreeing collectively. This was also reflected through further questioning, as the majority also agreed that they could understand recommendations made by their physician over the phone (90% somewhat to strongly agreed). In addition, participants were generally satisfied with the quality of sound provided through teleconsultations, with 58% strongly agreeing.
Although overall, 88% somewhat to strongly agreed with their telemedicine experience, we found that if given a choice, most of the participants would prefer face-to-face consultations over teleconsultations (68% vs. 32%, respectively). However, the majority would still be willing to participate in future telemedicine consultations (90% vs. 10%, respectively).

| DISCUSSION
This pandemic has set in motion a fleeting utilization of telemedicine in cancer care. With the best of our knowledge this is the first review regarding patients' satisfaction of telemedicine in Qatar. Incorporating a practical pathway approach to telemedicine, into our routine health care system needs careful planning. We proposed an outpatient workflow chart ( Figure 3) that can be adapted across different cancer center systems. Many cancer patients showed a positive attitude towards telemedicine.
We identified that, through their experience, 87% of respondents somewhat to strongly agreed that telemedicine was able to meet their care of needs. It is also possible that patients with predominately negative feedback were those with more disease severity and underlying depression, which is a major concern in cancer patients therefore affected such qualitative analytic studies. 37

ACKNOWLEDGMENT
The publication of this article was funded by the Qatar National Library.

CONFLICT OF INTEREST
The authors declare no conflict of interest. Note: Abdulqadir J.
Nashwan is an Editorial Board member of Health Science Reports and co-authorco-author of this article. He is excluded from editorial decision-making related to the acceptance of this article for publication in the journal.

DATA AVAILABILITY STATEMENT
All data generated during this study are included in this published article. [Dr. Israa Elhakeem] had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

TRANSPARENCY STATEMENT
The lead author (Dr. Israa Elhakeem) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.